Long-Yau Lin

Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh

The purpose of this study was to evaluate the effectiveness of the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh in patients with severe (stage III or IV) anterior vaginal prolapse. Thirty-eight consecutive women were enlisted for this prospective study. The procedure consisted of an extensive vaginal dissection to join the vesicovaginal and retropubic space and an anchoring of a polypropylene mesh patch between the two Arcus Tendineus Fasciae Pelvis in a tension-free manner. The mean age of the study group was 63 (33–80) years. The success rate was 87% (33/38) at a mean follow-up interval of 21 (12–29) months. A total of eight (100%) patients were also cured of concomitant stress incontinence (five overt and three occult type) with an additional tension-free vaginal tape (TVT) operation. During follow-up, there were five de-novo stress incontinence cases (16.7%) and four vaginal erosions of mesh (10.5%). Four clinical variables—diabetes mellitus, recurrent anterior vaginal prolapse, chronic cough and vaginal erosions of mesh—were found to have a significant correlation with an unsatisfactory surgical result with large values of hazard ratios found by survival analysis. We concluded that the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh was effective for most, but failed in some patients who had specific risk factors within short convalescence periods. Concomitant stress incontinence can be successfully treated by a TVT operation in combination with the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. However, the anterior colporrhaphy procedure may itself have adverse effects on urethral sphincter function.

Nm23-H1: a metastasis-associated gene.

The protein product of nm23-H1 gene has activity of nucleoside diphosphate (NDP) kinase, which catalyzes the phosphorylation of nucleoside diphosphates to the corresponding nucleoside triphosphates. Reductions in nm23 expression have been significantly associated with aggressive behavior in melanoma, breast, colon, and gastric carcinomas. On the contrary, high levels of nm23 gene expression are noted in the advanced stage of thyroid carcinomas and associated with significant reductions in survival for neuroblastoma and osteosarcoma patients. Although expression of nm23/NDP kinase is divergent in various malignant tumors, its reduced expression seems to be related to increased metastatic potential in most carcinoma types. However, it is hypothesized that nm23 may play a tissue-specific role, and that different regulatory mechanisms may act in different tumors. In ovarian carcinoma, nm23-H1/NDP kinase may be correlated with some clinicopathologic characteristics. In cervical cancer, nm23-H1 is probably involved in cervical carcinogenesis and correlated with some aggressive parameters. Overexpression of nm23-H1 protein may indicate poor survival for cervical cancer patients. Other than histidine 118 residue (amino acid sequence 118: histidine) concerned with NDP kinase activity of nm23-H1, serine 120 (amino acid sequence 120: serine) related activity of histidine-dependent protein phosphotransfer was recently reported to be responsible for its biological suppressive effects. To inhibit metastatic potential, nm23-H1 is also demonstrated to co-immunoprecipitate the kinase suppressor of Ras and phosphorylate it, and therefore reduce activation of the extracellular signal-regulated kinase mitogen-activated protein kinase pathway in response to signaling.

Is the occurrence of storage and voiding dysfunction affected by menopausal transition or associated with the normal aging process

ObjectivesTo evaluate whether the increasing occurrence of urinary and voiding dysfunction is independently influenced by the transition from pre- to postmenopause or by the interactive and additive effects of age-associated changes in bladder and urethral function. DesignOf the 1,584 women randomly sampled from a community-based health population, 1,253 (79.1%) were successfully interviewed. The participants were asked to reply to the Bristol Female Urinary Tract Symptoms Questionnaire regarding various storage symptoms and voiding dysfunction. The &khgr;2 test and Cochran-Armitage trend test were used for analysis. ResultsThe prevalence of storage symptoms such as frequency, urgency, nocturia, and urge incontinence in premenopausal and menopausal groups was 18.0% versus 29.8%, 9.8% versus 20.7%, 21.2% versus 38.2%, and 6.8% versus 15.7%, respectively (all P < 0.05). In premenopausal and menopausal groups, the prevalence of hesitancy, poor stream, incomplete emptying, voiding with abdominal straining, discontinuous urine flow, and dribbling was also significantly different (17.2% v 22.9%, 17.8% v 25.7%, 12.7% v 21.9%, 4.9% v 11.6%, 16.2% v 24.5%, and 9.4% v 17.6%, respectively; all P < 0.05). However, the occurrences of various storage symptoms, namely, frequency, urgency, nocturia, and urge incontinence, as well as voiding symptoms such as incomplete emptying, discontinuous urine flow, and dribbling, were also significantly associated with the normal aging process (P < 0.05). ConclusionsOur results imply that the increasing occurrences of storage and voiding dysfunctions are not only affected by pre- and postmenopausal transition but are also closely associated with aging changes.

Applicability of perineal sonography in anatomical evaluation of bladder neck in women with and without genuine stress incontinence

Thirty‐seven patients with proven genuine stress incontinence (GSI) underwent ultrasound study to evaluate the bladder neck position relative to the symphysis pubis. Sixty‐five continent women including 40 parous and 25 nulliparous women were recruited as a control group. Several parameters were found to be statistically different between incontinent and control groups (P < 0.01). If 28 degrees or 13 mm were used as the cut‐off point for rotational angle (RA) and descent of bladder neck (DBN), the sensitivity, specificity, and positive and negative predictive values were 73.0%, 76.9%, 64.3%, and 83.3%, respectively. The specificity and positive predictive value for GSI increased to 83.1% and 67.6% if these two parameters were used together. Perineal sonography is valuable in assessing anatomic change of the bladder neck, but it is not a sensitive tool for predicting GSI.

Anorectal dysfunction in women with urinary incontinence or lower urinary tract symptoms.

Objectives: (1) To evaluate the prevalence of anorectal dysfunction among women with urinary storage or voiding symptoms; and (2) to investigate the risk factors associated with anorectal symptoms. Methods: A sample of 320 women who attended the urogynecology outpatient clinic for urodynamic evaluation were requested to complete a structured questionnaire. The information collected included the medical, surgical, gynecological, and obstetric histories of the patients. Anal incontinence was defined as involuntary leakage of solid or liquid feces or gas. Constipation was defined as less than three bowel movements per week. Prevalence was estimated for anal incontinence and for constipation. A chi‐square test was used to compare risk factors between women with and without anal incontinence or constipation. We used a multi‐variable logistic regression analysis to estimate the association between other variables. Result: Forty‐nine (15.9%) women reported having anal incontinence according to the above definition. Of those 49 women, 11 (3.6%) experienced leakage of liquid and/or solid feces and 38 (12.3%) had flatus incontinence. Constipation was reported by 100 (31.5%) of the women. A multiple logistic regression analysis revealed that the main risk factor associated with anal incontinence and constipation was the presence of uterovaginal prolapse (odds ratio=5.02; 95% CI=2.19–11.5 for anal incontinence; odds ratio=1.78; 95% CI=1.03–3.09 for constipation). Conclusion: Our results demonstrate a relatively high prevalence of anal incontinence or constipation among women suffering from urinary dysfunction. Uterovaginal prolapse is the main risk factor associated with anorectal dysfunction.

Clinical significance of matrix metalloproteinase-2 in cancer of uterine cervix : A semiquantitative study of immunoreactivities using tissue array

OBJECTIVES To study the expression of matrix metalloproteinase-2 (MMP-2) in cancer of uterine cervix and correlate its expression with clinicopathological parameters, recurrence and survival of patients. METHODS Twenty cervical cancer and 20 normal tissues from the same patients were collected to detect MMP-2 mRNA expression. From them, 16 cancer and 16 normal tissues were collected and added with another 64 cancer tissues to construct a 96-tissue core microarray for immunohistochemical study. We evaluated the relationships among MMP-2 immunoreactivity using semiquantitative H scores, obtained by multiplying proportion score of stained cells and their mean digital density, and clinicopathological variables, recurrence and survival in cervical cancer patients. We used univariate and multivariate analyses of all parameters for recurrence and survival, further including time interval for evaluation. RESULTS MMP-2 mRNA expression was higher in most of cervical cancerous tissues than normal counterparts. H score of MMP-2 was significantly higher in cancerous tissue cores than normal counterparts (median H scores: 1.5 vs. 0.3, P<0.001). MMP-2 expression was significantly associated with parametrium invasion (P=0.004) and lymph node metastasis (P=0.015), but not with cancer recurrence, recurrence-free and overall survival rates of these patients. However, poor tumor cell differentiation and positive parametrium invasion significantly increased the recurrence and poor cell differentiation increased the risk of death. CONCLUSIONS MMP-2 is highly expressed in cervical cancer tissues at mRNA and protein levels and associated with lymph node metastasis and parametrium invasion but not predictive of recurrence and survival in cervical cancer patients.

Imaging comparison of basic cardiac views between two- and three-dimensional ultrasound in normal fetuses in anterior spine positions.

Objective: When the fetal spine is in anterior position, it shadows the fetal heart, resulting in the difficult visualization using two-dimensional (2D) ultrasound. The purpose of this study was to compare the basic cardiac views of normal fetuses between 2D and 3D ultrasound to demonstrate whether 3D ultrasound improved the visualization of these views in fetuses in anterior spine positions. In addition, inter- and intra-observation reliabilities of basic cardiac views using 3D ultrasound were evaluated for their clinical applicability. Methods: Using a multiplanar technique, integrated 3D ultrasound was used to display the four-chamber view, aortic outflow tract and pulmonary outflow tract in fetuses in anterior spine positions for 23 uncomplicated singleton pregnant women. The imaging visualizations of these views for the 23 fetuses in 3D ultrasound were compared with those in 2D ultrasound using the McNemar test. We also evaluated the inter- and intra-observation differences of each basic cardiac view in 3D ultrasound using the κ statistic and McNemar test, respectively. Results: Only in the pulmonary outflow tract, 3D ultrasound had significantly better visualization than the 2D ultrasound in the fetuses in anterior spine positions (p < 0.05). There was good inter-observation reliability and no intra-observation differences for the technique were observed. Conclusions: Among the basic cardiac views in fetuses in anterior spine positions, 3D ultrasound improved the visualization of pulmonary outflow and provided reliable alternate technique for clinical use.

Analysis of two sling procedures using polypropylene mesh for treatment of stress urinary incontinence.

Objectives: To evaluate and compare the surgical outcome between the innovative tension‐free vaginal tape (TVT) and conventional pubovaginal sling (PVS) procedures using polypropylene mesh. Methods: Eighty consecutive women with urodynamic stress urinary incontinence (SUI), who chose to undergo either a TVT (n=23) or a PVS (n=57) procedure using polypropylene mesh based on financial consideration, were recruited for this study. The surgical results were analyzed and compared subjectively and objectively. Results: The mean follow‐up interval was 23 months for the TVT and 20 months for the PVS procedure (P=0.062). Postoperatively, SUI (91.3% vs. 93.0%), concomitant urge symptoms (85.0% vs. 85.3%) and the negative impact of incontinence and urogenital distress on patients’ quality of life (79.8% vs. 77.8%) (77.4% vs. 68.8%) had improved markedly. After a multivariable logistic regression analysis, the treatment outcome of SUI was found to be independent of the main effects of patient age, parity, concurrent gynecological surgeries, intrinsic sphincter deficiency, previous failed incontinence surgeries, and concomitant urge symptoms. However, it was significantly related to treatment procedures (TVT vs. PVS) and their interaction with patient body mass index (BMI). Based on the fitted logistic model, we see that TVT performs better than PVS when BMI is less than 27.27 kg/m2, and the advantage of TVT decreases as BMI increases. Conclusion: Both TVT and PVS procedures using polypropylene mesh are effective treatment modalities for female SUI. However, TVT was not as effective in treating overweight or obese women as PVS.

Human Nonmetastatic Clone 23 Type 1 Gene Suppresses Migration of Cervical Cancer Cells and Enhances the Migration Inhibition of Fungal Immunomodulatory Protein From Ganoderma tsugae

The authors investigate the effects of human nonmetastatic clone 23 type 1 (nm23-H1 ) gene and fungal immunomodulatory protein—Ganoderma tsugae (FIP-gts) on the metastatic potential of cervical cancer cells and assess whether nm23-H1 can influence the action of FIP-gts using cell migration and invasion assays and gelatin zymography. The nm23-H1 gene was stably transfected into Caski cells, which lacked nm23-H1 expression. The results show that nm23-H1 stably transfected Caski cells exhibit reduced cell migration but no change of cell invasion and matrix metalloproteinase (MMP)—2 and —9 activities. FIP-gts reduced cell migration in SiHa and nm23-H1 transfected Caski cells more significantly compared with Caski cells and reduced invasion in Caski and nm23-H1—transfected Caski cells, but it exerted no influence on MMP-2 and MMP-9 activities in them. Conclusively, the nm23-H1 gene suppresses cervical cancer cell migration but not invasion and activities of MMP-2 and MMP-9 and enhances the inhibition of FIP-gts upon migration.

A significant elevation of plasma level of matrix metalloproteinase-9 in patients with high-grade intraepithelial neoplasia and early squamous cell carcinoma of the uterine cervix

The objective of this article is to study the correlation between plasma levels of matrix metalloproteinase—2 and —9 (MMP-2 and MMP-9) and multisteps of cervical carcinogenesis as well as to evaluate their clinical application. Two hundred one blood samples were collected from 52 patients with early cervical squamous cell carcinoma (SCC), 41 with high-grade cervical intraepithelial neoplasia (CIN), 27 with low-grade CIN, and 81 healthy individuals. Enzyme-linked immunosorbent assay was used to detect plasma MMP-2 and MMP-9 concentrations. Gelatin zymography was used to directly compare the activities of MMP-2 and MMP-9 and to measure the MMP-9:MMP-2 ratio. A receiver-operating characteristic curve was plotted to determine the plasma cuto f levels of these biomarkers. Patients with low- and high-grade CIN were found to have significantly di ferent plasma MMP-9 levels (P < .001) but not MMP-2 levels. The cuto f values of 103.8 ng/mL for plasma MMP-9 and 0.70 for the MMP-9:MMP-2 ratio were used to distinguish SCC and high-grade CIN from low-grade CIN and healthy cases. The sensitivities and negative predictive values of these cuto f points were high (75.6% and 75.8% for MMP-9; 79.6% and 79.8% for the MMP-9:MMP-2 ratio). A significant elevation of plasma MMP-9 levels and the MMP-9:MMP-2 ratio in high-grade CIN and SCC patients manifests a stage point of high-grade CIN in cervical carcinogenesis and can be used as additional molecular information. Once plasma MMP-9 levels fall below 103.8 ng/mL or the MMP-9:MMP-2 ratio falls below 0.70, patients have only about a 20% chance of developing these cervical lesions.